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An Overview on Food & Drug Interactions

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 An Overview on Food & Drug Interactions
Subhashis Debnath*, R. Tejovathi, Niranjan Babu, T. H. Harish Kumar
Department of Pharmaceutics, Seven Hills College of Pharmacy, Tirupati, India.

Astract:
Food & drug interactions result from medicines, reacting with food or beverages in the diet. Some drugs will not give expected effect if taken
with particular food. The food alters the pharmacokinetics, pharmacodynamics and therapeutic activity of the drug. Food-drug interactions may
lead to loss of therapeutic efficacy, toxicity or therapeutic failure. Pharmacists should give suggestions while taking certain foods.
Key Word: Food, drug, medicines, pharmacokinetics

Introduction: Food and drug interactions are frequently caused by chelation with
components in food. In addition, the physiological response to food
Drug Interaction:
intake in particular gastric acid secretions may reduce or increase the
Drug interaction is an interaction between a drug and some other bioavailability of certain drugs [2].
substance, such as another drug or a certain type of food, which prevents
the drug from working correctly. Adverse Food-Drug interactions:
• Prevents the therapeutic effect of a medicine.
• Make a side effect worse.
• Cause a new side effect.

Drug Interaction Risk Factors and Importance

Most people have the mistaken belief that being natural, all herbs and
foods are safe. It cannot be said that it is true. Constantly, herbs and foods
may interact with medications normally taken, that result in serious side
reactions. Experts suggest that natural does not mean it is completely
safe. The medication that is taken by mouth travels through the digestive
system in the same way as food and herbs taken orally do. When drugs
and certain foods are taken at the same time, they might interact in such
a way that decreases the effectiveness of the ingested drug or reduce
the absorption [3, 4].

Fig 1: Interaction of drug with another drug and food How Drugs React in the Body
In order to understand food/drug and drug/nutrient interactions, it is
important to understand how drugs work in the body. There are four stages
The drug, whose activity is affected by such interactions is called as of drug action for medicines administered orally:
the object drug, and the agent which precipitates such an interaction is
referred to as the precipitant. • Stage 1: The drug dissolves into a useable form in the stomach.
• Stage 2: The drug is absorbed into blood and is transported to its site
An interaction can either increase or decrease the effectiveness and/ of action.
or the side effects of a drug, or it can create a new side effect not seen
before. • Stage 3: The body responds to the drug and the drug performs its
function.
Drug interactions include- • Stage 4: The drug is excreted from the body either by the kidney, liver,
1. Drug – drug interaction (eg: Ketoconazole interacts with antacids, or both [3].
decreases dissolution bioavailability)
2. Food – drug interactions (eg: Inhibition of metabolism of several Factors affecting the extent of interaction between food and drugs:
drugs by grape fruit juice) The impact of food and drug interactions depends on a variety of
3. Chemical – drug interactions (eg: Interaction of a drug with alcohol, intervening factors like:
tobacco or environmental chemicals) • Dosage of the drug.
4. Drug – disease interactions (eg: Worsening of disease condition by • Sex.
the drug) • Person’s age.
Food-drug interaction is defined as alteration of pharmacodynamics • Size or weight of the person.
or pharmacokinetics of a drug or nutritional element or a compromise in • State of the health.
nutritional status as a result of the addition of the drug [1]. • Time of the drug taken.

*E-mail: shcp7@yahoo.com

Pharma Times - Vol. 49 - No. 04 - April 2017 9

 Apart from these, the time foods and the medications are taken, also Table 3: Examples of specific counseling on some drug-food interaction
play an important role. Avoidance of drug interactions does not necessarily
mean avoiding drugs or foods. In case of tetracycline and dairy products, Drug Effects and Precautions
these should simply be taken at different times; rather than eliminating Antibiotics Take on an empty stomach to speed absorption
one or the other. Sufficient information about the medications and timing Cephalosporins, of the drugs. Don’t take with fruit juice or wine,
of medications around food intake can help to avoid drug interaction penicillin, which decreases the drug’s effectiveness.
problems [5]. Erythromycin, Increase the risk of Vitamin B12 deficiency.
Sulfa drugs, Dairy products reduce the drug’s effectiveness.
Mechanisms of Drug-Food Interactions: Tetracycline Lowers Vitamin C absorption.
Pharmacokinetic Interactions: Anticonvulsants Increase the risk of anemia and nerve problems
Drug Absorption Interactions: Dilantin, Phenobarbital due to deficiency of folalte and other B vitamins.
Food may affect drug absorption in the GI tract by altering gastric Antidepressants Reduce appetite and can lead to excessive
pH, secretion, gastrointestinal motility and transit time. This may result Fluoxetine weight loss
in a change in the rate of absorption or extent of drug absorption or both. Lithium A low-salt diet increases the risk of lithium
For example, azithromycin absorption is decreased when it is taken with toxicity; excessive salt reduces the drug’s
food, resulting in a 43% reduction in bioavailability. Sustained-release efficacy.
theophylline products, when taken with high-fat foods, may cause a Tricyclics Many foods, especially legumes, meat, fish
sudden release (dose dumping) of theophylline, resulting in increased and foods high in Vitamin C, reduce absorption
theophylline concentrations and possible toxicity. Children are more prone of the drugs.
to this interaction than adults.
Antihypertensives, Take on an empty stomach to improve the
Table 1: Some examples of drug-food interactions that delay the Heart Medications absorption of the drugs.
absorption of drugs ACE inhibitors Take with liquid or food to avoid excessive
Alpha blockers drop in blood pressure.
Drug Mechanism Conclusion Digitalis Avoid taking with milk and high fiber foods,
which reduce absorption, increases potassium
Aceta- High pectin foods act as Take on empty stomach, if
loss.
minophen adsorbant and protectant. not contraindicated.
Diuretics Increase the risk of potassium deficiency.
Digoxin High–fiber, high–pectin Take drug at the same time Potassium sparing Unless a doctor advises otherwise, don’t take
foods bind to the drug. as food. Avoid taking with diuretics diuretics with potassium supplements or
high-fiber foods. salt substitutes, which can cause potassium
overload.
Levodopa Drug competes with Avoid taking drug with
amino acids for absorption high–protein foods. Asthma Drugs Avoid caffeine, which increases feelings of
transport. Pseudoephedrine anxiety and nervousness.
Theophylline High protein diet reduces absorption. Caffeine
Glipizide Mechanism unknown. Affects blood glucose; more increases the risk of drug toxicity.
potent when taken half an Heartburn and Ulcer Interfere with the absorption of many minerals;
hour before meals. Medications for maximum benefit, take medication one
Quinidine Possibly protein binding. May take with food to Antacids, hour after eating.
prevent gastrointestinal Cimetidine, Avoid high protein foods, caffeine and other
upset. Famotidine, Sucralfate items that increase stomach acidity.
Hormone Salty foods increase fluid retention. Drugs
Methyldopa Competitive absorption. Avoid taking with high-
Preparations reduce the absorption of folate, vitamin B6 and
protein foods.
Oral contraceptives other nutrients; increase intake of foods high in
Sulfonamides Mechanism unknown. Taking with meals may these nutrients to avoid deficiencies.
prolong gastric emptying. Salty foods increase fluid retention. Increase
Steroids intake of foods high in calcium, vitamin K,
Tetracyclines Binds with calcium ions or Take one hour before or two potassium and protein to avoid deficiencies.
iron salts forming insoluble hours after meals; do not Thyroid drugs Iodine-rich foods lower the drug’s efficacy.
chelates. take with milk.
Laxatives Overuse can cause a deficiency of vitamins
Table 2: Some examples of drug-food interactions that accelerate Mineral Oils A, D, E, and K.
the absorption of drugs Painkillers Always take with food to lower the risk of
Aspirin and stronger gastrointestinal irritation; avoid taking with
Drug Mechanism Conclusion
nonsteroidal alcohol, which increases the risk of bleeding.
Griseofulvin Drug is lipid soluble, enhanced Take with high- antiinflammatory Frequent use of these drugs lowers the
absorption with high-fat foods fat foods. drugs absorption of folate and vitamin C.
Propranolol Food may reduce first-pass Take with food. Codeine Increase fiber and water intake to avoid
extraction and metabolism. constipation.

Spironolactone Delayed gastric emptying permits Take with food. Sleeping Pills, Never take with alcohol. Caffeine increases
dissolution and absorption, bile may Tranquilizers anxiety and reduce drug’s effectiveness.
solubilize the drug. Benzodiazepines

Pharma Times - Vol. 49 - No. 04 - April 2017 10

 In other cases, the components of the food, such as calcium or iron,
may form complexes with the drug that are less easily absorbed. Examples
include tetracycline, sodium fluoride and ciprofloxacin. The absorption of
alendronate is impaired by food, calcium and almost everything, including
orange juice and coffee. It should be taken with plain water and nothing
else should be consumed for at least 30 minutes. In many cases, the actual
mechanism by which food interferes with absorption is not known. Delayed
absorption does not necessarily reduce the total overall exposure to the
drug; the area under the curve (AUC) may be equivalent regardless of how
the drug is taken. A reduced rate of absorption may sometimes be useful
in reducing the side effects of a drug, as in the case of ibuprofen, without
reducing bioavailability. The bioavailability of some drugs may be enhanced
by food. For example, an acidic environment is necessary for the absorption
of ketoconazole. The absorption of griseofulvin is increased by fat in a
meal. Fenofibrate, mebendazole, isotretinoin, tamsulosin, carbamazpine
Where E= enzyme, S= substrate, P= product, I = inducer
and labetalol are examples of drugs that will be better absorbed when
taken with food. Improved absorption of a drug may or may not have a Fig 2: Competitive inhibition of drug absorption by nutrients.
significant effect on the drugs efficacy. Patients taking digoxin should
avoid taking bran fiber, pectin-containing foods such as apples or pears,
or fiber containing, bulk-forming laxatives at the same time, since these 6. Blood flow to the liver: Blood flow to the GIT and liver increases
agents may bind to the digoxin, decreasing its absorption. This interaction shortly after a meal. This increased blood flow to the liver will increase
could result in decreased serum concentrations of digoxin and therapeutic the rate at which drugs are presented to the liver. The metabolism of
effectiveness. It is advisable to take some medications with food to some drugs are sensitive to their rate of presentation to the liver. The
reduce gastrointestinal irritation and possible nausea. Examples of these greater the rate of presentation of such drugs to the liver, the larger
medications include potassium supplements, ferrous sulfate, nonsteroidal the fraction of drugs that escapes first-pass metabolism.
anti-inflammatory drugs, estrogen, prednisone, tacrine, terfenadine and
nitrofurantoin. Cholesterol-lowering agent, lovastatin, should be taken
with food to enhance gastrointestinal absorption and bioavailability.
Simvastatin, pravastatin and fluvastatin may be taken without regard to
food [2, 4]. Examples of some drug food interactions which accelerate and
delay the absorption of drugs are shown in table 1 and table 2 respectively
with the brief counseling.
Food provides a viscous environment which will reduce the rate of
drug dissolution and drug diffusion to the absorbing membrane. Drugs may
also bind to food particles or react with gastrointestinal fluids secreted in Fig 3: (a) Tetracycline and (b) calcium complex of tetracycline
response to the presence of food.
Drug Metabolism:
Food may influence drug bioavailability by means of the following
mechanisms: Food may alter the hepatic metabolism of some drugs. It has been
reported that, when administered with the antihypertensive drug felodipine,
1. Increased viscosity of gastro-intestinal contents: results in
concentrated grapefruit juice caused an increase in the bioavailability of
reduction in the rate of dissolution in the GI contents. Absorbing surface
felodipine. The mean felodipine bioavailability with grapefruit juice was
may reduce by increasing viscocity.
284% (range 164%–469%) that of water. This resulted in lower diastolic
2. Alterations in the rate of gastric emptying: Hot solid meals containing blood pressure and increased heart rate in the male study volunteers.
high amount of fat tend to decrease the gastric emptying rate, there Adverse effects such as headaches, facial flushing and lightheadedness
by delaying the onset of action. were more common after ingestion of 250 ml grapefruit juice (125 ml
3. Stimulation of gastro intestinal secretions: Food stimulates frozen grapefruit concentrate plus 125 ml of water). The bioavailability of
secretions from the GIT, resulting in influence of drug stability & nifedipine with grapefruit juice was 134% (range 108%–169%) of that with
absorption rate. Due to chemical hydrolysis and enzymatic metabolism, water. Orange juice did not have these effects. It is postulated that flavonoid
there is a reduction of bioavailability. Bile salts and surface-active compounds in grapefruit juice concentrate inhibit cytochrome P-450
agents increases the absorption of drugs by increasing their rate of metabolism of felodipine and nifedipine. This interaction could increase
dissolution, eg: Griseofulvin. both the efficacy and toxicity of these calcium channel blockers. There
is of potential clinical significance, because citrus juices are frequently
4. Competitive inhibition of drug by food components: Drugs which
consumed at breakfast, when many medications are also taken. Patients
show a structural similarity with nutrients are also absorbed by the
should be advised of this possible interaction. (7, 8) First-pass hepatic
same mechanism. Therefore, there is a competitive inhibition to drug
metabolism of propranolol and metoprolol may be decreased when either
absorption in the presence of nutrients. Eg: levodopa.
medication is taken with food, thereby enhancing bioavailability. Drug
5. Complexation of drugs with dietary components: Tetracyclines from levels and therapeutic efficacy may be increased due to this interaction.
insoluble and non-absorbable complexes with calcium ions present in Monoamine oxidase (MAO) inhibitors are known to interact with foods
the diet. This is the reason for the reduced absorption of tetracyclines containing tyramine. Tyramine is normally inactivated by the enzyme
with administration along with milk. Food with high iron content also monoamine oxidase and this prevents tyramine from accumulating in the
reduce the bio-availability due to complexation. This is observed only body. Monoamine oxidase inhibitors cause increased levels of tyramine
when drugs form an irreversible or un absorbable complex with the which can lead to a hypertensive crisis. Patients taking monoamine oxidase
dietary components. inhibitors should avoid foods high in tyramine such as aged cheeses, pickled

Pharma Times - Vol. 49 - No. 04 - April 2017 11

fish, yeast extracts, red wine, some types of beer (including nonalcoholic still available to metabolise any tyramine in food stuffs. However, at higher
beer), fava beans and fermented products. High protein foods that have doses the selectivity of selegiline diminishes, and inhibition of the tyramine
been aged, fermented, pickled, smoked or bacterially contaminated are is more likely. Linezolid, a newer oxazolidone antibiotic, has some MAOI
unsafe for patients taking MAO inhibitors. Foods considered safe when properties, thus showing characteristics and potential for this interaction.
used fresh and in moderation include sour cream, yogurt, meat extracts, Therefore, linezolid should be used cautiously in patients taking Serotonin
chopped liver, dry sausage and alcoholic beverages. Selective Reuptake Inhibitors(SSRIs). This type of interaction shows hyper
sensitivity.
Drug Excretion:
Safety: Avoid foods and drinks with tyramine and foods with histamine
Foods may alter the urinary pH, which can affect the activity of certain
if you take isoniazid alone or combined with other antimycobacterials.
drugs. The half-lives of some medications can be significantly changed
by alterations in urinary pH. Therefore, the half-life of acidic drugs will High levels of tyramine can cause a sudden, dangerous increase in
be extended in acidic urine because the drug is in its unionized form. your blood pressure. Foods with histamine can cause headache, sweating,
However, the half-life of an acidic drug in alkaline urine is reduced because palpitations (rapid heart beats), flushing, and hypotension (low blood
the drug is in its ionized form. Foods such as milk, vegetables and citrus pressure). Follow your doctor’s directions very carefully.
fruits can alkalinize the urine. Meats, fish, cheese and eggs can acidify the
3. Potassium rich foods: Potassium rich foods (banana, spinach,
urine. Foods may alter the renal excretion of some medications. Lithium
apple, grapes, squash, tomato, etc.).
and sodium compete for tubular reabsorption in the kidney. A high-salt
diet causes more lithium to be excreted, whereas a low-salt diet causes Table 4: Examples of drugs taken with potassium rich foods & their
decreased renal excretion of lithium and an increase in serum lithium mechanism, ADR
levels.
Food Drug Mechanism ADR
Pharmacodynamic Interactions:
Potassium ACEIs (lisinopril,etc.,) • Lowering of Hyperkalemia
Foods may interact with medications by altering their pharmacologic rich food ARBs (losartan,etc.,) aldosterone
actions. Diets high in vitamin K may cause antagonism of warfarin and Direct renin inhibitors levels
decreased therapeutic efficacy of the anticoagulant. Foods rich in vitamin (aliskeron) or potas- • Increase
K include green leafy vegetables (kale, turnip greens, spinach, broccoli sium sparing diuretics potassium
and brussels sprouts), cauliflower, chick peas, green tea, pork liver and (spiranolactone, etc.) retention
beef liver. Alcoholic beverages may increase the central nervous system
depressant effects of medications such as benzodiazepines, antihistamines, Potassium Digoxin Increases Reduction of
antidepressants, antipsychotics, muscle relaxants, narcotics or any drug rich foods potassium theropeutic
with sedative actions. An example of a food potentiating the effect of a levels activity
medication is coffee, as caffeine has additive effects on theophylline. Safety: while taking above drugs, avoid potassium rich foods. Avoid
It has been reported that caffeine increases serum theophylline levels herbal supplements such as dandelion, gossypol, liquorice.
by 20%–30% and increases the half-life of theophylline by decreasing
clearance. Patients may complain of nervousness, tremor or insomnia. 4. Vitamin-k rich foods:
Caffeine has some bronchodilatory effects, which may enhance the effects Warfarin blocks the re-use of Vitamin K in liver.
of theophylline. A lower dosage of theophylline may be necessary for
those patients who consume excessive quantities of coffee (more than
6 cups daily).

Different Mecanisms of Food Taken With Drug:

1. Dairy products + drug:
When fluoroquinolons like ciprofloxacin, norfloxacin or tetracyclines
or bisphosponates like alendronate, risedronate & ibadronate, taken with
dairy products like cheese, yoghurt, milk containing multivalent cations Fig 4: Structure of Vitamin K
(calcium), leads to the formation of insoluble chelates, reduces the Vitamin K is vital for the formation of the clotting factors II, VII, IX and
absorption of the drug and reduces the therapeutic efficacy of the drug. X, as well as the anticoagulant proteins C and S.
Safety: Dairy products, which include buttermilk, cheese, milk and
yoghurt may interact with drugs chemically. To avoid that interaction,
calcium rich dairy products and calcium supplements should be taken
two hours before or six hours after administration of drug.

2. Tyramine Rich Foods + Non selective MAOIs or MAO-B

inhibitors:
Tyramine occurs in some aged cheese by the bacterial degradation
of milk and other proteins, firstly tyrosine and other amino acids, and the
subsequent decorboxylation of the tyrosine to tyramine. The reversible
inhibitors of mono amino oxidase(RIMAs) such as meclobemide and
toloxatone selectively inhibit MOA-A, which leaves MAO-B still available
to metabolize tyramine. Patients taking any of the non-selective MAOIs
should not eat foods reported to contain substantial amount of tyramine.
Rasagiline and selegiline specifically inhibit MAO-B, which leaves MAO-A Fig 5: Interaction of warfarin and vitamin K

Pharma Times - Vol. 49 - No. 04 - April 2017 12

 The chart above shows that Warfarin interferes with the vitamin K Table 6: Drugs taken with alcohol & their adverse effects
cycle. It interacts with the reductase enzyme, which means that oxidised
Drugs taken with Alcohol Adverse Effect or Side Effect
vitamin K cannot be converted back to vitamin K. This in turn means, as
shown above, that the amount of reduced vitamin K will also decrease. Metronidazole Flushing, headache, palpitations, nausea
The carboxylation of Precursor Prothrombin (Factor II) to Biologically and vomiting.
active Prothrombin requires reduced vitamin K. Hence, if the amount of Acetaminophen Increases liver toxicity.
reduced vitamin K is decreased, biologically active Prothrombin will not NSAIDs Higher intake of alcohol leads to stomach
be formed and hence the clotting pathway will be interrupted, leading to aspirin bleeding.
a reduction in blood coagulation. Celecoxib
Diclofenac
Safety: Suddenly increasing or decreasing intake of vitamin-K
Ibuprofen
rich foods can alter the effectiveness of the warfarin. So take greens in
Ketoprofen
consistent amount. Avoid drastic changes in consumption of foods high in
Naproxen
vitamin K like beef liver, cabbage, kale, soybean oil, broccoli, collard greens,
spinach, turnip greens, brussel sprouts, green tea, green leafy vegetables. Safety: avoid alcohol when taking any medications. If you drink three
or more alcoholic drinks every day, ask your doctor if you should use
5. Omega-3 fatty acid fish medicines with NSAIDs or other pain relievers/ fever reducers [7-10].
(Mackerel, Tuna, Salmon, Sturgeon, Mullet, Blue fish, etc.)
9. Caffeine (Coffee, Tea, Soft Drinks)
Anticoagulant/antiplatelet drugs (Aspirin, Clopidrogel, Ticlopidine,
Dipyridamole, Alteplace, Daltiparin, Enoxaparin, Heparin, Warfarin and Table 7: Examples of drugs taken with caffien their
others). Omega-3 fatty acid reacts with anticoagulants and potentiates mechanism and ADR
the anti-coagulant effects, increasing the risk of bleeding.
Drugs Taken with Mechanism Adr
Safety: It is recommended to consult the physician when the patients Caffeine
experience any unusual bleeding or swelling, vomiting, blood in urine or
stools, dizziness, weakness, during treatment with these medications. Oral contraceptives, Inhibits metabolism of Cardiac arrhythmia
Prednisone, caffeine. Increases effect
6. Protein-Rich Foods Interaction: Ciprofloxacin of caffeine
(Fish, chicken, Eggs, Beans, Nuts, etc.) Cimetidine
Table 5: Examples of drugs taken with protein binders & their Theophylline Inhibition of theophylline Jitteriness,
mechanism, ADR metabolism. increases Insomnia,
serum concentration of Cardiac arrhythmia
Food Drug Mechanism Adr theophylline.
Protein rich BETA Enhanced absorption Bradycardia,
foods BLOCKERS of propranolol. Hypotension, Bronchodilators Changes activity of Excitability,
Metaprolol Increases Broncho- bronchodilators. nervousness, rapid
propronolol bioavailability. constriction. heart beat

Protein rich Carbidopa Decreases Bradycardia,
foods Levodopa concentration & Hypotension,
Theophylline efficacy. Broncho-
constriction.
Safety: Don’t suddenly stop taking a beta blocker without talking to your
doctor. If you stop a beta blocker suddenly, you can get chest pain, an
irregular heartbeat, or a heart attack. Your doctor might tell you to decrease
your dose gradually.
7. Fibre Rich Foods: (Wheat bran, Oat bran, Rolled oats, Sunflower
seeds, Coconut shreds, Raisins, Bran muffins, green peas, beans)
When fibre rich foods reacts with Digoxin, Amoxicillin, Levothyroxine,
TCAs (Doxipine & Desipramine), fibre binds to the drug in the gut. Then
the absorption of drug will be delayed.
Safety: Avoid ingesting high fibre foods concomitantly with the drugs
mentired.
8. Alcohol: Alcohol affects body processes and interacts with many
drugs. Alcohol is a drug that interacts with almost every medications,
especially antidepressants and other drugs that effect the brain and
nervous system. For example, taking alcohol with metranidazole can cause
flushing, headache, palpitations, nausea and vomiting. Foods contain active
substances that interact against certain medications and can produce
unexpected or adverse effects. Pharmacist can give the information of
such interactions to the patients.
Safety: Better to avoid caffeine rich foods or drinks [11].
10. Fruit Juices:
When fruit juices or vegetables are taken with some drugs pharma-
cokinetic activity takes place in stomach. Here, drug-phytochemical
interaction takes place as therapeutic failure is less but more adverse
events will take place. Different juices interact with different drugs.
I. Grape Juice: Grape fruit juice and drug interactions are well known
interactions as compared to the other nutrients. However, its influence
on all drugs is not known. Grape fruit juice blocks cytochrome-P450 and
IA2 (CYP3A4 and CYP1A2) in intestinal area. This juice should not to be
taken with certain blood pressure-lowering drugs or cyclosporine for the
prevention of organ transplant rejection. The reason is that grapefruit
juice can cause higher levels of those medicines in the body, making side
effects from the medicine more likely. The juice can also interact to cause
higher blood levels of the anti-anxiety medicine Buspar (buspirone); the
antimalarial drugs Quinerva or Quinite (quinine); and Halcion (triazolam), a
medication used to treat insomnia. Excessive ingestion of grapefruit juice
increases the bioavailability of lovastatin, atorvastatin and simvastatin by
1400, 200 and 1500%, respectively. This may lead to drug accumulation
and the possible development of adverse effects. The components which
lead to all such negativite reactions in grapefruit juice are defined as
naringin, naringenin, furanokumarin, bergapten (5-methoxypsoralen) and
flavonoids [7,11-13].
II. Drugs With Grape Fruit Juice (GFJ) Gives Many Adverse Effects:

Pharma Times - Vol. 49 - No. 04 - April 2017 13

 Table 8: Examples of drugs taken with grape juice Orange Flexofenadine Decreases the Reduction of
their mechanism & ADR juice Aliskiren beta absorptionof drugs therapeutic
Drugs With Grape Mecahnism of Action Adverse Drug blockers (atenolol, by inhibiting the efficacy.
Juice Reactions Celeprolol, talindolol) OAPT (Organic
Or fluoroquinolones Anion Transporting
1. Statins: Furanocoumarins of Elevated risk of (ciprofloxacine, polypeptide).
Simvastatin grape-fruit juice rhabdomyolysis. Levofloxacine)
Lovastatin etc. inhibits the Pomelo Felodipine, Pomelo orange Increased risk
metabolism of statins. orange Cyclosporine or inhibits the of adverse
2. Erythromycine FJ induces the Increased risk of Tacrolimus CYP3A4 mediated effects.
Terfenadine prolongation of QT torsade de pointes metabolism
Ameoderone interval of heart beat Seville Dextrometharphen, Furanocoumarins Excessive
Droniderone by inhibiting the orange Felodipine of Seville orange adverse
Domperidone metabolism. juice inhibits effects.
Nilotinib CTP3A4 and
3. Calcium channel Inhibits the Hypotension, decrease the
blockers: metabolism of calcium Headache, flushing, metabolism.
Felodipine channel blockers. oedema Licorice: This would appear to be a fairly harmless snack food.
Manidipine However, for someone taking Lanoxin (digoxin), some forms of licorice may
Nisoldipine increase the risk for Lanoxin toxicity. Lanoxin is used to treat congestive
4. Oral Inhibits the Elevated risk of deep heart failure and abnormal heart rhythms. Licorice may also reduce the
Contraceptives; metabolism of vein thrombosis effects of blood pressure drugs or diuretic (urine-producing) drugs, including
Ethinylestradiol ethinylestradiol. Hydrodiuril (hydrochlorothiazide) and Aldactone (spironolactone).

5.Immuno GFJ inhibits the Elevated risk of Chocolate: MAO inhibitors are just one category of drugs that
suppresants: CYP3A4 mediated nephrotoxicity shouldn’t be consumed with excessive amounts of chocolate. The
Tacrolimus, metabolism. caffeine in chocolate can also interact with stimulant drugs such as Ritalin
Sirolimus (methylphenidate), increasing their effect, or by decreasing the effect of
Cyclosporine sedative-hypnotics such as Ambien (zolpidem)
6.Opioids: GFJ inhibits the Elevated risk of Role of Pharmacist In Prevention Of Drug-Food Interactions:
Oxycodone, CYP3A4 mediated respiratory depression Pharmacists in every practice setting need to be vigilant in monitoring
Fentanyl, Alfentanil metabolism. for potential drug-food interactions and advising patients regarding foods
7. Benzodiapezine: Inhibits the Excessive sedation or beverages to avoid when taking certain medications. It is imperative
Diazepam, Midazolam metabolism of and amnesia for pharmacists to keep up-to-date on potential drug-food interactions
Triazolam benzodiazepines. of medications, especially today’s new drugs, so that they may counsel
properly. In providing drug information to patients, pharmacists often
8. Selective Inhibits the Increased risk of
discuss potential side effects and how the medication should be taken.
Serotonin Reuptake metabolism of SSRIs. serotonin syndrome
It is important to provide information to patients on when to take their
Inhibitors (SSRIs):
medications in relation to food intake.
Fluoxetine, sertraline
The following information can be given to the patients while
Safety: Should not take grape juice with certain blood pressure dispensing the medicine.
lowering drugs or cyclosporine. Avoid drinking grapefruit juice when • Read the prescription label on the container. If you do not understand
taking the following drugs: Calcium channel blockers, Opioids, Selective something or think you need more information, ask your physician or
Serotonin Reuptake Inhibitors, Oral contraceptives, Immunosuppresants, pharmacist.
Anafranil, Buspar, Cardizem, Cordarone/Pacerone, Crixivan, Cyclosporine,
• Read directions, warnings and interaction precautions printed on
Halcion, Invirase, Lipitor, Mevacor, Nimotop, Norvasc, Plendil, Procardia,
all medication labels and package inserts. Even over-the-counter
Prograf, Quinidine, Rapamune, Sporanox, Sular, Tegretol, Valium, Verapamil,
medications can cause problems.
Versed, Xanax, Zocor [11].
• Take medication with a full glass of water.
Other Fruit Juices Interaction: • Do not stir medication into your food or take capsules apart
(unless directed by your physician). This may affect the efficacy of
Table 10: Examples of some of fruit juices reacts with different
medication.
drugs & their ADR
• Do not take vitamin pills at the same time you take medication. Vitamins
JUICE DRUG MOA ADR and minerals can interact with some drugs.
• Do not mix medication into hot drinks because the heat from the drink
Apple juice Flexofenadine AJ inhibits Diminished
may destroy the effectiveness of the drug.
(AJ) Cyclosporine OAPT (Organinc therapeutic
Aliskiren Anion Transport efficacy. • Never take medication with alcoholic drinks.
Polypeptide) and • Be sure to tell your physician and pharmacist about all medications
decreases the you are taking, both prescription and nonprescription.
absorption of drug. • Check with the pharmacist on how food can affect specific medications
taken with the food.

Pharma Times - Vol. 49 - No. 04 - April 2017 14

Precautions to be taken :
• Medications need to be taken at different times relative to meals.
• Consult a physician when health problems persist.
• During pregnancy and nursing always consult a physician or pharmacist
before taking any medication. Drugs taken by the mother may affect
the infant.
• Check with a doctor or pharmacist for the proper way and time to take
medication [6].
Conclusion
Food and drugs, both are necessary for good health, but they some
times also bring side effects and risks when used at same time.Thus, the
interactions need to be well identified. Generally, the effect of food on drugs
results in a reduction in the drug’s bioavailability, however, food can also
alter drug clearance. Drugs can influence food intake, digestion, absorption
and excretions. Much more research is needed for identification of this
kind of interactions, and pharmacists should be aware of the necessity
of monitoring for potential drug-food interactions and advising patients
regarding foods or beverages to avoid when taking certain medications.
The interactions are not always detrimental to therapy, but can in some
cases be used to improve drug absorption or to minimize adverse effects.
These interactions have received more attention recently, especially drug
interactions with grapefruit juice. As new drug approvals occur with ever
Letter to Editor
Call to Pharmacy Teachers for Inspiring Students to open
Pharmacy
Community Pharmacy is the best option before a pharmacy pass-out
student to earn better livelihood, with respect and dignity. At the same time,
the enactment of ‘Pharmacy Practice Regulations, 2015’ is an additional
tool for establishing the important role of pharmacist among masses. Due
to absence of proper counselling during student life, pharmacy students
are in dilemma and search job after passing. Sometimes the miscreants
misguide them, to get their registration on lending. Running a Pharmacy
is the best option before such pass-out students.
In this regard it is interesting to note that our Union Government
has notified ‘Jan Aushadhi Generic Medicine Scheme’ through BPPI.
Accordingly, the government has decided to launch a country wide
Jan Aushadhi Campaign for ensuring availability of quality medicines
Report: “52nd Annual Conference of the Indian Hospital Pharmacists’ Association”
52nd IHPA Annual Conference was organized on 28th January, 2017,
at ITS College of Pharmacy, Ghaziabad, India. It was co-organized by
ITS College of Pharmacy, Surya Hospital
& Healthcare Division-Vardaan Welfare
Society, and supported by Hospital
Pharmacy Foundation of IHPA. The theme
of the Conference was 'Role of Pharmacists
in Ensuring Patient Safety: Prescribing
Generic Medicine & ADR Monitoring'.
Hon’ble Chief Guest Dr. G. N. Singh, Drugs
Controller General (India) inaugurated the
mega event by lighting the lamp. Mr. S.
L. Nasa, President, IHPA, told that the
Association put forth the demand of creating the posts of Joint Director,
Pharmacy Services, in the Directorate General office of the Health
services, Govt. of India, immediately, and Pharmacists to be awarded
pay structure admissible to other degree holders. Mr. R. A. Gupta,
Vice President, IHPA & Convener appealed the delegates, Pharmacists,
Pharmacy students and citizens of India to send a letter in support to
Govt. of India initiative (draft amendment dated 28th December, 2016)
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increasing speed, there is less information available about their adverse
effects and interactions when the drugs reach the market.
Reference:
1. Venkateswarulu, Biopharamaceutics & Pharmacokinetics, Pharma Med Press,
2nd ed:72 -73, 2014.
2. Bobroff B.L., Lentz A., Turner E.R., Food/Drug AND Drug/nutrient. Univ. florida
IFAS, 4th ed:1-10,2009.
3. Yaheya M., Ismail M., Drug food interactions and role of pharmacist ,Asian
J.Pharm. Clin. Res. 2009, 2: 1-10.
4. Zyl VM, The effects of food on nutrition. S.Afr. J.CLIN Nutr. 24(3): 38-41,
2011.
5. Hepler CD and Strand LM, Opportunities and responsibilities in pharmaceutical
care. Am. J. Hosp.Pharm, 1990, 47: 533-43.
6. www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/Buying
7. www.fda.gov/ForConsumers/ConsumerUpdates/ucm096386.htm
8. file:///C:/Users/user/Desktop/New%20folder%20(2)/SVH%20Drug%20
Interactions.PDF
9. http://www.merckmanuals.com/professional/nutritional-disorders/nutrition-
general-considerations/nutrient-drug-interactions
10. http://www.merckmanuals.com/professional/nutritional-disorders/nutrition-
general-considerations/nutrient-drug-interactions
11. http://www.fda.gov/forconsumers/consumerupdates/ucm096386.htm
12. http://www.heart.org/HEARTORG/Conditions/More/MyHeartandStrokeNews/
Medication-Interactions-Food-Supplements-and-Other-Drugs_UCM_437377_
Article.jsp#.V7ZlF49OLIU
13. http://www.cc.nih.gov/ccc/patient_education/drug_nutrient/coumadin1.pdf
at affordable prices to masses. The Government supports this scheme
financially. Rs. 2.50 lakh is provided as grant with drug and sufficient
profit margin. This scheme is also available on PCI website for
encouraging Pharmacists to start their own retail drug generic store.
Till date, only around 400 stores were opened. Further, Government
has targeted opening of 6000 stores. Opening of a Pharmacy where
pharmacist can provide their professional services to masses. Why not
6000 pharmacists come ahead by submitting their applications within
this month to BPPI?
In view of above, I appeal our pharmacy teachers to inspire their pass-
out students /unemployed pharmacists to open their own drug store by
utilising the current government scheme.
Dr. R. N. Gupta
Ex Vice-President, IPA & Professor, Department of Pharmaceutical
Sciences & Technology, Birla Institute of Technology, Mesra, Ranchi.
to issue new wholesale Drug license to registered Pharmacists
only, as to eradicate the counterfeit drugs from the country.
We lc ome a d d r e s s wa s g ive n b y
Organizing Chairman, Dr. S. Sadish Kumar.
Mr. Puneet Gupta, Organizing Secretary,
elaborated about the theme and
programme. Eminent speakers Dr. A.
Ramkishan, Deputy Drugs Controller India,
CDSCO, New Delhi; Dr. Jyotsna Sharma;
Dr. Vijit Agrawal; Mr. Pramod K. Adusumilli;
PvPI, IPC, MoH&FW, GoI, Ghaziabad;
Mr. Joseph Mathew, Sr. Manager-
Pharmacovigilance, Cliniminds, Noida;
and Dr. Arvind K. Gupta, Managing Director, Pharmasynth Formulations
Ltd. Hon’ble chairpersons for the scientific sessions were Dr. Ajay
Sachan, Mr. S. L. Nasa, Mr. R. A. Gupta, Dr. A. K. Adhikari, Dr. Satish K.
Sharma, Mr. Rajesh Srivastava, Mr. Sushant Sharma, Dr. G. T. Kulkarni,
Dr. Jagannath Sahoo, Dr. Tanveer Naved, Dr. Monika Sachdeva and
Dr. Satyendra K. Rajput.
Pharma Times - Vol. 49 - No. 04 - April 2017 15